A nurse is caring for an immobile client. What is the priority assessment in this client?
Assessment for the presence of peripheral edema
Auscultation of lung sounds
Auscultation of bowel sounds
Assessment of skin turgor
The Correct Answer is B
Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.
Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.
Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.
Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Primary intention is the correct answer, because it is the type of wound healing that occurs when the wound edges are approximated and closed with sutures, staples, or glue. Primary intention is the fastest and most effective way of wound healing, as it minimizes tissue loss, infection, and scarring.
Choice B reason: Secondary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are not approximated and left open to heal by granulation, contraction, and epithelialization. Secondary intention is the slowest and least effective way of wound healing, as it results in more tissue loss, infection, and scarring.
Choice C reason: Tertiary intention is not the correct answer, because it is the type of wound healing that occurs when the wound edges are initially left open and then closed with sutures, staples, or glue after a period of time. Tertiary intention is a delayed form of primary intention, and it is used when the wound is contaminated, infected, or requires drainage.
Choice D reason: Binary intention is not the correct answer, because it is not a real term for wound healing. Binary intention is a madeup term that does not describe any specific process or outcome of wound healing.
Correct Answer is D
Explanation
Choice A reason: Intermittent flatus and minor abdominal discomfort are not signs that would prompt the nurse to call the provider immediately. They are common and expected after surgery and anesthesia. They indicate that the client's bowel function is returning to normal.
Choice B reason: A minor headache and taking an overthe counter pain pill at home are not signs that would prompt the nurse to call the provider immediately. They are mild and manageable symptoms that may be related to stress, dehydration, or caffeine withdrawal. They do not indicate a serious complication or adverse reaction.
Choice C reason: Refusing pain medication and doing physical therapy are not signs that would prompt the nurse to call the provider immediately. They are indicators of the client's preference and motivation to recover. They may also suggest that the client's pain is wellcontrolled or tolerable.
Choice D reason: Paresthesia in the fingers and intense increasing pain in the shoulder are signs that would prompt the nurse to call the provider immediately. They are indicators of a possible nerve injury, compression, or ischemia that may result from the surgery, swelling, or hematoma. They may also indicate a worsening of the client's rheumatoid arthritis or a development of a complex regional pain syndrome. They require prompt assessment and intervention to prevent permanent damage or disability.
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